Health inspection·December 12, 2024

42 CFR § 483.25(d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR § 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 11/7/2024, the California Department of Public Health (CDPH) received a facility reported incident (FRI) regarding Resident 1 who was hit by a shower room door and sustain an injury to a left great toe. On 11/22/2024 CDPH conducted unannounced visit to the facility to investigate the FRI allegation. The facility failed to: 1. Ensure Certified Nurse Assistant (CNA 1) requested assistance to hold the door to Shower Room 1 while he was pulling Resident 1 on a shower chair into the Shower Room 1. 2. Ensure CNA 1 and Licensed Vocational Nurse (LVN 1) reported Shower Room 1's door malfunctioning by documenting about it in the Maintenance Logbook. 3. Ensure CNA 1 and LVN 1 reported to the Maintenance Supervisor (MS) that the door to Shower Room 1 was not staying wide open to transport the residents safely through the Shower Room 1. 3. Ensure MS followed the facility's policy and procedure (P&P) titled, "Maintenance Service," which indicated "The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times." As a result, Resident 1 left great toe was hit by the door to Shower Room 1 and sustaining a fracture (broken bone) of the left medial (middle) cortex (outer layer) of the left fourth proximal (closer to center of the body) phalanx (small toe bone) and a left great toe laceration (skin tear). On 11/16/2024 Resident 1 was transferred to a general acute care hospital (GACH) where the resident had the left great toe sutured (a medical thread used by doctors to stitch up a wound or cut). Findings: A review of Resident 1's Admission Record, indicated Resident 1 was admitted to the facility on 3/24/2017 with diagnoses including Alzheimer's Disease (a disease characterized by a progressive decline mental abilities) and osteoporosis (disorder of bone density and structure). A review of Resident 1's Minimum Date Set ([MDS]- a resident assessment tool), dated 10/4/2024, indicated Resident 1 had impairment in cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting, personal hygiene, and lower body dressing. A review of Resident 1's Change of Condition ([COC]- documentation of a resident's sudden change from regular state of being) assessment dated 11/6/2024, indicated Resident 1's physician was notified of Resident 1 had left great toe hit by a shower room door on 11/6/2024 at 10:30 a.m. A review of Resident 1's Physician's Orders Summary Report for November 2024, indicated an order dated 11/6/2024 to transfer Resident 1 to the emergency room (ER) via ambulance (a vehicle that transports people who are sick or injured to the hospital in an emergency) for a left great toe wound treatment. A review of Resident 1's Radiology (x-ray-imaging that creates pictures of the inside of the body) Final Report, dated 11/6/2024 at 1:58 p.m., indicated Resident 1 had the distal medial cortex of the left fourth proximal phalanx fracture. A review of Resident 1's Emergency Department (ED) Discharge Instructions from the GACH dated 11/6/2024, indicated to remove the resident's left foot sutures in seven to 10 days. A review of Resident 1's Interdisciplinary Team ([IDT]- group of different professionals working together in a case, all collaborating to provide the best care for a patient) Skin Note dated 11/7/2024, indicated Resident 1 was transferred to the GACH for 11/6/2024 or the left foot wound evaluation and treatment and was transferred back to the facility the same day (11/6/2024) with intact sutures on a left great toe wound (laceration). A review of CNA 1's written statement dated 11/7/2024, indicated CNA 1 was pulling Resident 1 on a shower chair into Shower Room 1 while "using my right foot to stop the door then the resident's left foot was accidentally hit by the door." A review of the facility's Maintenance Logbook for the period of 7/26/2024 -11/20/2024 located at Nurses Station 1, indicated no documentation regarding Shower Room 1's door malfunctioning. A review of Resident 1's Nurses Progress Notes dated 11/22/2024, indicated there were four sutures removed from Resident 1's great left toe laceration and Resident 1 received Tylenol (medication used to relieve pain) for pain management. Resident 25 was not able to state the pain level but had a facial grimacing (a facial expression that usually conveys pain) indicating the resident was in pain. During an observation on 11/22/2024 at 9:20 a.m., of Resident 1's left great toe wound (laceration) dressing change, Resident 1's left great toe wound was observed being without redness or swelling. During an interview on 11/22/2024 at 9:35 a.m., CNA 1 stated on 11/6/2024, he was transporting Resident 1 on a shower chair to Shower Room 1, and while trying to pull the resident inside, the door to the shower room would not stay open, causing the door to hit Resident 1's left foot. CNA 1 stated he should have requested help while attempting to pull Resident 1 into the shower room to avoid the door striking Resident 1's left foot. CNA 1 stated that he verbally informed LVN 1 on 11/6/2024 about the malfunctioning door of Shower Room 1, but he did not record it in the Maintenance Logbook. CNA 1 stated it was the facility's policy to document broken equipment in the Maintenance Logbook. CNA 1 acknowledged that he should have documented about malfunctioning shower door in the Maintenance Logbook. CNA 1 stated the incident with Resident 1 could have been avoided if the door to Shower Room 1 had been working properly. During an interview on 11/22/2024 at 10:20 a.m., LVN 1 stated Shower Room 1's door had a stopper (device used to keep a door open or closed) that prevented the door from being fully opened or stay open, so staff needed to use their foot to keep the door propped open. LVN 1 stated CNA 1 should have requested someone to hold the door for him while he was pulling Resident 1 on a shower chair into the shower room, which could have prevented Resident 1's foot from being struck. LVN 1 stated that she did not consider reporting the shower room door failure to stay open because it had always functioned that way, and she did not see it as being broken since the door stopper was a part of the door. LVN 1 stated she did not think the shower room door was a problem until it hit Resident 1's foot. During an interview on 11/22/2024 at 11:27 a.m., the MS stated Shower Room 1's door was closing automatically unless facility staff was holding door open. MS stated that the week before Resident 1's accident on 11/6/2024, staff (unknown) informed MS that there was an issue with the Shower Room 1's door. MS stated on 11/5/2024, he removed the door stopper to allow the door to open wider, but someone (unknown) reattached it. During a concurrent interview and record review on 11/22/2024 at 12:45 p.m., Registered Nurse Supervisor (RNS) stated due to the accident on 11/6/2024 Resident 1 sustained a wound (laceration) to the left great toe that required suturing. RNS stated that CNA 1 should have asked for assistance to keep door open while transporting/pulling Resident 1 on a shower chair into the shower room to prevent the accident. RNS 1 stated CNA 1 should have documented in the Maintenance Logbook that Shower Room 1's door was not staying open and was malfunctioning. After reviewing the Maintenance Logbook, RNS 1 stated there was no documentation regarding the malfunctioning Shower Room 1's door. During an interview on 11/22/2024 at 1:01 p.m., the Administrator (ADM) stated when there were equipment issues or repairs needed, staff was expected to document these problems in the Maintenance Logbook. The ADM stated that CNA 1 should have reported (documented) the issue with the Shower Room 1's door, as this could have prevented the accident involving Resident 1. A review of the facility's policy and procedure (P&P) titled, "Maintenance Services," revised 12/2009, indicated, "The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Maintaining the building in good repair and free from hazards." A review of the facility's P&P titled "Homelike Environment," revised 2/2024, indicated, "Residents are provided with a safe, clean, comfortable, and homelike environment." The facility failed to: 1. Ensure CNA 1 requested assistance to hold the door to Shower Room 1 while he was pulling Resident 1 on a shower chair into the Shower Room 1. 2. Ensure CNA 1 and LVN 1 reported Shower Room 1's door malfunctioning by documenting about it in the Maintenance Logbook. 3. Ensure CNA 1 and LVN 1 reported to the MS that the door to Shower Room 1 was not staying wide open to transport the residents safely through the Shower Room 1. 3. Ensure MS followed the facility's policy and procedure (P&P) titled, "Maintenance Service," which indicated "The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times." As a result, Resident 1 left great toe hit by door to Shower Room 1 and sustaining a fracture of the left medial cortex of the left fourth proximal phalanx and a left great toe laceration. On 11/16/2024 Resident 1 was transferred to a GACH where the resident had the left great toe sutured (a medical thread used by doctors to stitch up a wound or cut). These violations, jointly, separately, or in combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.